Royal College of Speech & Language Therapists Clinical Guidelines: 5.5 Cleft Palate & Velopharyngeal Abnormalities
Taylor-Goh, S. (ed). (2005).
Bicester (United Kingdom): Speechmark Publishing Ltd., 41-47.
This guideline provides recommendations for the assessment and treatment of cleft palate and velopharyngeal abnormalities. The target audience for this guideline is speech-language pathologists.
Royal College of Speech & Language Therapists (United Kingdom)
<div>"[Speech] therapy for consonant production may be appropriate when there is excessive nasal airflow/hypernasal resonance as a result of velopharyngeal dysfunction. Therapy is aimed at establishing correct oral placements, albeit with nasal airflow/hypernasal resonance. Where there is a diagnosis of phoneme-specific nasality, this is an indication of velopharyngeal mislearning and should be eliminated with therapy and not surgery or prosthetics" (Grade B Evidence; p. 46).</div>
<div>"The perceptual assessment of speech has a central position in the assessment of velopharyngeal dysfunction. Hypernasality and/or excessive nasal emission/turbulence and/or certain characteristics of consonant production are usually indicative of velopharyngeal dysfunction and should prompt referral … for investigations of velopharyngeal function" (Grade C Evidence; p. 43).</div>
<div>Hearing should be assessed as part of a systematic speech evaluation to inform clinical decision making for individuals with cleft lip/palate (Grade B Evidence).</div>
<div>"Electropalatography should be a treatment option for school-aged children and older patients with persistent articulatory disorders" (Grade B Evidence; p. 45).</div>
<div>"The SLP is responsible for reporting speech outcomes that inform surgical decisions regarding the timing and techniques of primary palate surgery" (Grade B Evidence; p. 41).</div>
<div>Non-speech oral motor treatments including palatal exercises, massage, blowing, sucking, icing, interrupted swallowing, cheek puffing, and gagging are considered inappropriate interventions for managing speech disorders secondary to velopharyngeal dysfunction (Grade C Evidence).</div>
<div>"Visual biofeedback, although still experimental, may be a useful technique in therapy where there is inconsistent velopharyngeal closure" (Grade A Evidence; p. 46).</div>
<div>"Routine assessments of pre-speech, speech and emerging language should begin after palate repair with particular reference to nasal tone, consonant repertoire, hearing and oral structure" (Grade B Evidence; p. 42).</div>
<div>Speech-language pathologists, as part of the cleft team, should contribute to decision-making in management of speech consequences of velopharyngeal dysfunction with surgery. Pre- and post-operative assessments should be completed, with "results used in the joint recommendations to determine the nature of surgery" (Grade B Evidence; p. 45).</div>
<div>"Velopharyngeal dysfunction resulting in hypernasality/nasal airflow can be effectively managed with a palatal lift or speech bulb obturator. It is an appropriate option to consider when surgery and/or therapy have failed or are contraindicated" (Grade B Evidence; p. 46).</div>
<div>"Techniques using oral-nasal auditory discrimination, increased speaking effort, greater mouth opening and reduced speaking rate may have a place, but only when the patient is capable of achieving velopharyngeal closure. This must be established by direct visualisation of the velopharyngeal mechanism using nasendoscopy/videofluoroscopy" (Grade C Evidence; pp. 44-45).</div>
<div>In-depth assessment of language is recommended when screening indicates a delay (Grade B Evidence).</div>
<div>"Differential diagnosis of velopharyngeal dysfunction based on direct and indirect methods of visualisation of the velopharygeal sphincter should usually include as a minimum: videofluoroscopy and perceptual evaluation. Nasendoscopy, acoustic and airflow measurements should also be carried out wherever possible" (Grade B Evidence; p. 43).</div>
<div>"The SLP will explain to parents about the function of the velopharyngeal mechanism in speech. The SLP will monitor communication development in relation to the cleft palate and hearing, and will offer advice and support until speech and language are established. The target for the majority of children should be normal speech by school entry, or earlier if possible" (Grade C Evidence; p. 43).</div>
<div>It is recommend that speech-language pathologists work collaboratively with health professionals in the management of dysphagia and feeding (Grade A Evidence).</div>
<div>Systematic speech assessment and phonological interpretation of speech is recommended to inform clinical decision making. Areas to be assessed include:</div>
<ul>
<li>hypernasal resonance;</li>
<li>nasal airflow;</li>
<li>nasal/facial grimace;</li>
<li>voice quality;</li>
<li>articulation; and </li>
<li>contributing factors: e.g., oral structure, hearing, dental occlusion, dentition, lip closure, nasal airway, social and emotional issues, and associated conditions/syndromes (Grade B Evidence).</li>
</ul>
<div>SLPs should work collaboratively with audiologists if concerns with hearing are present which may affect communication (Grade B Evidence).</div>
<div>"The therapy [program] for cleft palate children is based on a comprehensive assessment and [is] tailored to the individual. This may include articulatory, phonological or combined articulatory and phonological approaches. Objectives may target normal or adaptive articulation. Intervention may be necessary from a very young age into adulthood. Extended periods of therapy input may be necessary. Intensive therapy has been shown to be effective in both individual and group therapy contexts" (Grade A Evidence; p. 44).</div>
